Professional Documents
Culture Documents
1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication?
A. Checking the client's blood pressure Correct
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on
the morning of the test." Correct
D. "I need to take a laxative after the test is completed, because the liquid that Ill have to drink for
the test can be constipating."
2-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the physician's answering
service and is told that the physician is off for the night and will be available in the morning. The
nurse should:
A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician Correct
C. Withhold the medication until the physician can be reached in the morning
D. Administer the medication but consult the physician when he becomes available
4.
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial
infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the
sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid
pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the
nurse is:
A. Documenting the findings
B. Asking the ED physician to check the client Correct
C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an MI
5.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the
client's record and notes that the client routinely takes an oral antihypertensive medication each
morning. The nurse should:
A. Administer the antihypertensive with a small sip of water Correct
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration on the day after the ECT
6 A client who recently underwent coronary artery bypass graft surgery comes to the physician's
office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed.
Which response by the nurse is therapeutic?
A.
B.
C.
D.
7 A client in labor experiences spontaneous rupture of the membranes. The nurse immediately
counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes
that the fluid is yellow and has a strong odor. Which of the following actions should be the nurses
priority?
A.
B.
C.
D.
8 A nurse has assisted a physician in inserting a central venous access device into a client with a
diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the
catheter, the nurse immediately plans to:
A.
B.
C.
D.
E.
9 A rape victim being treated in the emergency department says to the nurse, "Im really worried that
Ive got HIV now." What is the appropriate response by the nurse?
11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and
650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours,
diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley
catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening
shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total
intake during the 24-hour period? Type your answer in the space provided.
Answer: ________mL
Correct Responses: "1670"
12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client
for the management of anxiety. The nurse prepares the medication as prescribed and administers
the medication over a period of:
A.
B.
C.
D.
3 minutes Correct
10 seconds
15 seconds
30 minutes
13 A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus
infection, asks the client about medications that he is taking. The client tells the nurse that he is
taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines
that the client most likely has a history of:
A.
B.
C.
D.
Depression Correct
Diabetes mellitus
Hyperthyroidism
Coronary artery disease
14 Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the medication and tells the client to contact the
physician immediately if she experiences:
A. Dry mouth
B. Restlessness
C. Feelings of depression
D. Neck stiffness or soreness Correct
15 Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the
treatment of a psychotic disorder. Which finding in the clients medical record would prompt the nurse
to contact the prescribing physician before administering the medication?
A.
B.
C.
D.
16 A client who has been undergoing long-term therapy with an antipsychotic medication is admitted
to the inpatient mental health unit. Which of the following findings does the nurse, knowing that longterm use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client?
A.
B.
C.
D.
Fever
Diarrhea
Hypertension
Tongue protrusion Correct
17 A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which
of the following diagnoses, if noted on the client's record, would indicate a need to contact the
physician who is scheduled to perform the ECT?
C. History of glaucoma
D. Peripheral vascular disease
18 A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the
surgery. The client later asks the nurse to explain again how the prostate is going to be removed.
The nurse tells the client that the prostate will be removed through:
A.
B.
C.
D.
19 A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer.
Which of the following recommendations does the nurse include on the poster? Select all that
apply.
A.
B.
C.
D.
E.
20 A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of
the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation,
which finding would the nurse expect to note on assessment of the clients breast?
A.
B.
Correct
C.
D.
21 The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a
member of the school soccer team and expresses concern about her child's participation in sports.
The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose
control, tells the mother:
22 A client with chronic renal failure who will require dialysis three times a week for the rest of his life
says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter
what I do if Im never going to get better!" On the basis of the client's statement, the nurse
determines that the client is experiencing which problem?
A.
B.
C.
D.
Anxiety
Powerlessness Correct
Ineffective coping
Disturbed body image
23 A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to
talk and shows little interest in participating in hygiene care. Which statement by the nurse would be
therapeutic?
A.
B.
C.
D.
24 Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client
for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse,
assisting the physician with the procedure, expect to note?
A.
B.
C.
D.
25 An emergency department nurse is told that a client with carbon monoxide poisoning resulting
from a suicide attempt is being brought to the hospital by emergency medical services. Which
intervention will the nurse carry out as a priority upon arrival of the client?
A.
B.
C.
D.
26 A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work
and worried about how he will care financially for his wife and three small children. On the basis of
the client's concern, which problem does the nurse identify?
A.
B.
C.
D.
Anxiety Correct
Powerlessness
Disruption of thought processes
Inability to maintain health
27 A nurse, performing an assessment of a client who has been admitted to the hospital with
suspected silicosis, is gathering both subjective and objective data. Which question by the nurse
would elicit data specific to the cause of this disorder?
A.
B.
C.
D.
A.
B.
C.
D.
30 A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines
that the client is gaining a therapeutic effect from the medication after noting:
A. Bradycardia
B. Increased heart rate
C. Decreased blood pressure
A.
B.
C.
D.
Insomnia
Rigidity and akinesia
Bilateral lung wheezes Correct
Orthostatic hypotension
32 A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information
regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include
in the pamphlet?Select all that apply.
A.
B.
C.
D.
E.
Smoking Correct
A high-calcium diet
High alcohol intake Correct
White or Asian ethnicity Correct
Participation in physical activities that promote flexibility and muscle strength
A.
B.
C.
D.
Corn
Cocoa
Peaches
Sardines Correct
34 A nurse is providing information to a client with acute gout about home care. Which of the
following measures does the nurse tell the client to take? Select all that apply.
A.
B.
C.
D.
E.
35 A nurse is gathering subjective and objective data from a client with suspected rheumatoid
arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that
apply.
A.
B.
C.
D.
E.
Fatigue Correct
Anemia
Weight loss
Low-grade fever Correct
Joint deformities
36 A nurse is reviewing the medical record of a client with a suspected systemic lupus
erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the
clients medical record? Select all that apply.
A.
B.
C.
D.
E.
Fever Correct
Vasculitis Correct
Weight gain
Increased energy
Abdominal pain Correct
37 A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate).
Which of the following foods does the nurse tell the client to avoid while she is taking this
medication? Select all that apply.
A.
B.
C.
D.
E.
F.
Beer Correct
Apples
Yogurt Correct
Baked haddock
Pickled herring Correct
Roasted fresh potatoes
38 The blood serum level of imipramine is determined in a client who is being treated for depression
with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this
result, the nurse should:
A.
B.
C.
D.
39 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for
the treatment of bipolar disorder. Which of these statements by the client indicate a need for further
instruction? Select all that apply.
A.
B.
C.
D.
E.
40 A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large
volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On
the basis of these findings, the nurse should:
A.
B.
C.
D.
41 A client with agoraphobia will undergo systematic desensitization through graduated exposure. In
explaining the treatment to the client, the nurse tells the client that this technique involves:
A.
B.
C.
D.
42 A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The
client says to the nurse, "Im really thirsty may I have something to drink?" Before giving the client
a drink, the nurse should:
A.
B.
C.
D.
43 A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern
does the nurse recognize as the priority?
A.
B.
C.
D.
Inability to cope
Decreased nutrition
Decreased fluid volume Correct
Inability to tolerate activity
44 A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse
explains to the client that amniocentesis is often performed during the third trimester to determine:
A.
B.
C.
D.
45 A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of
these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply.
A.
B.
C.
D.
E.
F.
Bananas
Potatoes
Spinach Correct
Legumes Correct
Whole grains Correct
Milk products
46 A nurse caring for a client with preeclampsia prepares for the administration of an intravenous
infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available
at the client's bedside?
A.
B.
C.
D.
Vitamin K
Protamine sulfate
Potassium chloride
Calcium gluconate Correct
A.
B.
C.
D.
48 A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the
client that:
D. Urinary protein must be measured and that the physician should be notified if the results
indicate a trace amount of protein
49 A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of
the following information elicited during the assessment indicate that the condition has not yet
resolved? Type the option number that is the correct answer.
Answer: __ Correct Responses: "1"____
Nursing Progress Notes
1. Hyperreflexia is present.
2. Urinary protein is not detectable.
3. Urine output is 45 mL/hr.
4. Blood pressure is 128/78 mm Hg.
50 A nurse is caring for a client who sustained a missed abortion during the second trimester of
pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the
client?
A.
B.
C.
D.
51 A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse
monitoring the client notes uterine hypertonicity and immediately:
A.
B.
C.
D.
52 A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor
tracing (see figure). Which of the following actions should the nurse take as a result of this
observation?
A.
B.
C.
D.
53 A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which
adverse effect of cisplatin will the nurse assess the client?
A.
B.
C.
D.
Nausea
Bloody urine
Hearing loss Correct
Electrocardiographic changes
54 A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing
vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of
the client?
A.
B.
C.
D.
55 A nurse assisting with a delivery is monitoring the client for placental separation after the delivery
of a viable newborn. Which of the following observations indicates to the nurse that placental
separation has occurred?
A.
B.
C.
D.
A discoid uterus
Sudden sharp vaginal pain
Shortening of the umbilical cord
A sudden gush of dark blood from the introitus Correct
A.
B.
C.
D.
57 A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy
for the treatment of cancer. Which statement by the client indicates a need for further instruction?
A.
B.
C.
D.
58 An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic
dehydration. What findings does the nurse expect to note during the admission assessment? Select
all that apply.
B.
C.
D.
E.
F.
59 An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid
restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have
between 7 a.m. and 3 p.m.?Type your answer in the space provided.
Answer ____mL
Correct Responses: "350"
60 A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and
potassium restriction between dialysis treatments. The nurse determines that the client understands
this restriction if the client states that it is acceptable to use:
A.
B.
C.
D.
Salt substitutes
Herbs and spices Correct
Salt with cooking only
Processed foods as desired
61 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary
disease (COPD). Which of the following menu selections by the client tells the nurse that the client
understands the instructions?
A.
B.
C.
D.
Coffee
Broccoli
Cheeseburger Correct
Chocolate milk
62 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the
relief of choreiform movements. Of which common side effect does the nurse warn the client?
A.
B.
C.
D.
Headache
Drowsiness Correct
Photophobia
Urinary frequency
63 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase
(Retavase). For which adverse effect of the medication does the nurse monitor the client?
A.
B.
C.
D.
Diarrhea
Vomiting
Epistaxis Correct
Epigastric pain
64 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses
how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to
permit assessment of whether the infant is receiving an adequate amount of milk?
A.
B.
C.
D.
Count the number of times that the infant swallows during a feeding
Weigh the infant every day and check for a daily weight gain of 2 oz
Count wet diapers to be sure that the infant is having at least six to 10 each day Correct
Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the
infant
65 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic
(TLSO) brace, and the nurse provides information to the mother about the brace. Which statement
by the mother indicates a need for further information?
A.
B.
C.
D.
66 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take
the medication with:
A.
B.
C.
D.
Milk
Water
Any meal
Tomato juice Correct
67 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse
provides information to the client about dietary and insulin needs and tells the client that during the
first trimester, insulin needs generally:
A.
B.
C.
D.
Increase
Decrease Correct
Remain unchanged
Double from what they normally are
68 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on
the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a
persistent depression. On the basis of this finding, the nurse concludes that:
A.
B.
C.
D.
No edema is present
The client is dehydrated
Pitting edema is present Correct
Blood is not pooling in the extremities
69 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+
(i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:
A.
B.
C.
D.
70 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling
of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate
intervention does the nurse prepare the client?
A.
B.
C.
D.
Hysterectomy
Insertion of an indwelling catheter
Administration of oxytocin (Pitocin)
Replacement of the uterus through the vagina into a normal position Correct
71 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours
ago. The nurse checks the client's temperature and notes that it is 100.4 F (38 C). On the basis of
this finding, the nurse would:
A.
B.
C.
D.
72 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at
the umbilicus, and that it has shifted from the midline position to the right. The nurses initial action
should be:
A.
B.
C.
D.
Anxiety Correct
Premature grief
Fluid volume loss
Fluid volume overload
74 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis
who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would
indicate to the nurse that DIC has developed in the client?
Tachycardia Correct
Cool, clammy skin
Decreased respiratory rate
Diminished peripheral pulses Correct
Urine output of less than 30 mL/hr
76- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing
measures to be implemented in the event of the development of shock. After contacting the
physician, which of the following does the nurse specify as the first action in the event of shock?
A.
B.
C.
D.
77 -A postpartum nurse provides information to a client who has delivered a healthy newborn about
normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells
the client to report to the physician?
A.
B.
C.
D.
A.
B.
C.
D.
79- A maternity nurse providing an education session to a group of expectant mothers describes the
purpose of the placenta. Which statement by one of the women attending the session indicates a
need for further discussion of the purpose of the placenta?
A.
B.
C.
D.
80 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the
first day of her last menstrual period (LMP) was September 25, 2012. Using Nageles rule, the nurse
determines that the estimated date of delivery (EDD) is:
A.
B.
C.
D.
June 2, 2013
July 2, 2013 Correct
October 2, 2013
September 18, 2013
81 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does
the nurse instruct the client to limit consumption of while taking this medication?
A. Steak Correct
B. Spinach
C. Chicken
D. Oranges
82 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing
chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect
of the chemotherapy?
A.
B.
C.
D.
83 -Which finding in a clients history indicates the greatest risk of cervical cancer to the nurse?
A.
B.
C.
D.
Nulliparity
Early menarche
Multiple sexual partners Correct
Hormone-replacement therapy
84 -A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does
the nurse interpret this finding?
A.
B.
C.
D.
85- A client who has undergone abdominal hysterectomy asks the nurse when she will be able to
resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:
A. At any time after the surgery
B. When menstruation resumes
C. When pelvic sensation and response to stimuli return
D. In about 6 weeks, when the vaginal vault is satisfactorily healed Correct
86 -A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the
treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery
is:
A.
B.
C.
D.
87- A nurse is caring for a client with community-acquired pneumonia who is being treated with
levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the
medication, does the nurse monitor the client?
A.
B.
C.
D.
Fever Correct
Dizziness
Flatulence
Drowsiness
88 -A nurse is providing instructions to a client with glaucoma who will be using acetazolamide
(Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to
report to the physician?
A.
B.
C.
D.
Nausea
Dark urine Correct
Urinary frequency
Decreased appetite
89 -A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical
ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of
tube, does the nurse implement?
A.
B.
C.
D.
Frequent suctioning
Maintaining cuff pressure Correct
Maintaining mechanical ventilation settings
Alternating the use of a cuffed tube with a cuffless tube on a daily basis
90 - A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse
place the client before inserting the tube?
A.
B.
C.
D.
Correct
91 -Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions
does the nurse implement? Select all that apply.
A.
B.
C.
D.
E.
92 -A nurse, providing information to a client who has just been found to have diabetes mellitus,
gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on
being asked to list the symptoms, tells the nurse that the client understands the information? Select
all that apply.
A.
B.
C.
D.
E.
Hunger Correct
Weakness Correct
Blurred vision Correct
Increased thirst
Increased urine output
93- A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches.
The nurse reviews the physician's instructions, understanding that the gait was selected after
assessment of the client's:
A.
B.
C.
D.
94- A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral
tube feedings that will be continued after he is discharged home. When the nurse tells the client that
he will be taught how to administer the feedings, the client states, "I don't think Ill be able to do these
feedings by myself." Which response by the nurse is appropriate?
A. "Have you told your doctor how you feel?"
B. "Tell me more about your concerns regarding the tube feedings." Correct
C. "Don't worry. Well keep you in the hospital until youre ready to do them by yourself."
D. "Well ask the doctor about having a visiting nurse come to your home to give you your
feedings."
95- A client is brought to the emergency department after sustaining smoke inhalation. Humidified
oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are
measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis
of the ABG result, the nurse prepares to:
A.
B.
C.
D.
96- A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of
severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper
alignment is being maintained. Which of the following actions should the nurse take next?
A.
B.
C.
D.
97 -A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago.
The client tells the nurse that the skin is being irritated by the edges of the cast. What is the
appropriate action on the part of the nurse
A.
B.
C.
D.
98 -A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a
mass in my pancreas and that its probably cancer. Does this mean I'm going to die?" The nurse
interprets the client's initial reaction as:
A. Fear Correct
B. Denial
C. Acceptance
99 -A nurse notes documentation in the clients medical record indicating that the client has a stage II
pressure ulcer. On the basis of this information, which of the following findings does the nurse expect
to note?
A.
B.
C.
D.
Correct
100- A nurse is providing instruction in how to perform Kegel exercises to a client with stress
incontinence. The nurse tells the client to:
A. Always perform the exercises while lying down
B. Expect an improvement in the control of urine in about 1 week
C. Tighten the pelvic muscles for as long as 5 minutes, three or four times a day
D. Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 Correct
101 -Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following
occurrences does the nurse tell the client to report to the physician if she experiences them while
taking the medication?
A.
B.
C.
D.
Cough
Fatigue and lethargy
Dizziness and fatigue
Numbness and tingling of the fingers or toes Correct
102 -A client with posttraumatic stress disorder tells the nurse that he has stopped taking his
prescribed medication because he didn't like how the medication was making him feel. Which of the
following initial responses by the nurse is appropriate?
A.
B.
C.
D.
103- A nurse provides information to a client with peripheral vascular disease about ways to limit the
diseases progression. Which of the following measures does the nurse tell the client to take? Select
all that apply.
A.
B.
C.
D.
E.
104 -A client with depression is anorexic. Which measure does the nurse take to assist the client in
meeting nutritional needs?
A.
B.
C.
D.
105 -Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse
provides information about the medication and tells the client:
A.
B.
C.
D.
106 A client with depression is being encouraged to attend art therapy as part of the treatment plan.
The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is
therapeutic?
A.
B.
C.
D.
107 A hospitalized female client with mania enters the unit community room and says to a client who
is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the
appropriate response by the nurse?
A.
B.
C.
D.
108- A nurse working the evening shift is helping clients get ready for sleep. A female client with
mania is hyperactive and pacing the hallway. The appropriate nursing action is to:
A.
B.
C.
D.
109 -Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides
information to the client about the medication. Which statement by the client indicates to the nurse
that the client understands the information?
A.
B.
C.
D.
110 -A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which
of the following behaviors is a characteristic of the disorder?
A.
B.
C.
D.
Neediness
Perfectionism
Preoccupation with details
Hypersensitivity to negative evaluation Correct
111 -A female client admitted to the mental health unit tells the nurse that she cannot leave the
house without checking to be sure that she has shut off the coffee maker and unplugged her curling
iron. The client states that she even leaves the house, gets into her car, and then has to go back into
the house to check these appliances again and that these behaviors are interfering with her work
and social commitments. With which of the following anxiety disorders does the nurse associate this
client's symptoms?
A.
B.
C.
D.
Agoraphobia
Avoidant personality disorder
Obsessive-compulsive disorder Correct
Dependent personality disorder
112 -A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of
paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan
of care?
A.
B.
C.
D.
113 -A client on the mental health unit says to the nurse, "Everything is contaminated." The client
scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that
compulsive behavior:
A.
B.
C.
D.
114 -A male client arrives at the emergency department and reports to the nurse, "I woke up this
morning and couldn't move my arms." He also tells the nurse that he works in a factory and
witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine.
What is the priority response by the nurse?
A.
B.
C.
D.
Assessing the client for organic causes of loss of arm movement Correct
Calling the crisis intervention team and asking them to assess the client
Performing active and passive range-of-motion (ROM) exercises of the client's arms
Asking the client to move his arms and documenting the loss of movement he has experienced
115 -A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar
disorder. What does the nurse plan to do first?
A.
B.
C.
D.
116 -A client arrives in the emergency department and tells the nurse that she is experiencing
tingling in both hands and is unable to move her fingers. The client states that she has been unable
to work because of the problem. During the psychosocial assessment, the client reports that 2 days
earlier her husband told her that he wanted a separation and that she would have to support herself
financially. The nurse concludes that this client is exhibiting signs compatible with:
A. Severe anxiety
B. Conversion disorder Correct
C. Posttraumatic stress disorder (PTSD)
D. Obsessive-compulsive disorder
117 -A client experiencing delusions says to the nurse, "I am the only one who can save the world
from all of the terrorists." What is the appropriate response by the nurse?
A. "Tell me your plan for saving the world."
B. "Why do you think that you can accomplish this by yourself?"
C. "I don't think anyone can save the world from the terrorists by himself." Correct
D. "You must be powerful. Do you really believe that you can do this by yourself?"
118- A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with
cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What
does the nurse instruct the client to do during chemotherapy? Select all that apply.
A.
B.
C.
D.
E.
119- A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall
out?" The nurse responds by telling the client that:
Her hair will definitely fall out
She should not be worrying about her hair at this point
Her hair may fall out but will regrow after the chemotherapy is discontinued Correct
Vigorous hair-brushing is important while the client is undergoing chemotherapy to prevent hair
loss
120 -A nurse has given a client with viral hepatitis instructions about home care. Which of the
following statements by the client indicates to the nurse that the client needs further teaching?
A.
B.
C.
D.
A.
B.
C.
D.
121- A nurse provides home care instructions to a client who has undergone fluorescein
angiography. The nurse determines that the client needs further instruction if the client states that he
must:
A.
B.
C.
D.
122 -An emergency department nurse is assessing a client with acute closed-angle glaucoma.
Which of the following characteristics of the disorder does the nurse expect the client to exhibit?
Select all that apply.
A.
B.
C.
D.
E.
F.
Nausea Correct
Eye pain Correct
Vomiting Correct
Headache Correct
Diminished central vision
Increased light perception
123 - A nurse is measuring intraocular pressure by means of tonometry in a client who has just
been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note
in this client?
A.
B.
C.
D.
8 mm Hg
14 mm Hg
20 mm Hg
28 mm Hg Correct
124- An emergency department nurse assessing a client with Bell's palsy collects subjective and
objective data. Which of the following findings does the nurse expect to note?
A.
B.
C.
D.
A symmetrical smile
Tightening of all facial muscles
Ability to wrinkle the forehead on request
Complaints of inability to close the eye on the affected side Correct
125 A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing
vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most
appropriate?
A.
B.
C.
D.
126 A school nurse observing a child with Down syndrome is participating in a physical education
class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see
the child and conducts an assessment, during which the child complains of neck pain and loss of
bladder control. What is the appropriate action by the nurse in this situation?
A.
B.
C.
D.
127 -A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease.
What does the nurse ask the client during assessment for adverse effects of the medication?
A.
B.
C.
D.
128 -A nurse is providing instruction about insulin therapy and its administration to an adolescent
client who has just been found to have diabetes mellitus. Which statement by the client indicates a
need for further instruction?
A.
B.
C.
D.
129 -A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a
client with diabetes mellitus. The nurse tells the client that this blood test:
A.
B.
C.
D.
130- A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need
your help!" What is the appropriate way for the nurse to document this occurrence in the client's
record?
A.
B.
C.
D.
131 A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will
be admitted from the emergency department. Which item does the nurse give priority to placing at
the client's bedside?
A. Bedside commode
B. Suctioning equipment
C. Electrocardiography machine
D. Oxygen cannula and flowmeter Correct
132 -Cascara sagrada has been prescribed for a client with diminished colonic motor response as a
means of promoting defecation. The nurse provides information to the client about the medication
and tells the client to:
A.
B.
C.
D.